Who, What, Hair: do you have trichotillomania?

Are you pulling out your hair because of stress? In the first of my GTG hair care columns, I find out the truth about TTM and hair loss and the best ways to overcome it

Hair loss comes in many forms, categories and levels of severity and can be due to a wide range of reasons. Its causes can be far-reaching and extremely complex and one area that provides definitive proof of this is the subject of hair pulling, otherwise known as trichotillomania (TTM).

More common than many think, the condition unfortunately carries a stigma that’s proven particularly hard to shake - why do so few of those affected feel like they can’t talk about it? The reasons behind this are extensive, but it may be due to the fact that people, especially women, feel particularly shameful about admitting that they pull out their hair, perhaps seeing themselves responsible for the consequent hair loss that follows. This in fact though couldn’t be further from the truth. It’s a multifaceted form of hair loss, manifesting itself both physically and mentally. “Those living with trichotillomania often do not feel able to disclose their anxiety and it is not uncommon to find that the individual concerned to have additional mental health issues, including anxiety disorders and/or depression,” explains Nicky Lidbetter, CEO of Anxiety UK. “Many are unaware that trichotillomania is an anxiety disorder in its own right and as such are unaware of the treatment options available for this condition.”

With help available in a wide variety of ways to address it in both the short and long-term, I spoke with the hair loss experts to devise an effective TTM plan of action.

What is trichotillomania?

“The main feature of trichotillomania is the recurrent pulling out of one’s own hair which results in hair loss,” explains Nicky. “Sites of pulling hair may include any region of the body in which hair may grow (including axillary, pubic and perirectal regions), with the most common sites being the scalp, eyebrows and eyelashes.”

Categorised as an impulse-control disorder (ICD), the hair pulling can often feel like it’s out of your control. “Some people feel as though a single hair is grabbing their attention and calling them, resulting in them feeling around until they’ve found the one that releases the sensation,” says hair loss specialist and GTG ExpertLucinda Ellery. It is this specific attribute that makes it a particularly hard habit to break, and therefore requires assistance from both physical and mental health perspectives to best treat it.

What causes trichotillomania?

The condition’s roots are wide-ranging and its symptoms can be brought on in a variety of different ways. “The causes of trichotillomania can be complex,” says Anabel Kingsley, trichologist and hair care expert at Philip Kingsley. “In some cases, it’s unintentional and an individual may not be aware that they are doing it. However, for adults there may be a deep-rooted underlying cause.” When does this behaviour cross the line and become something that affects someone’s day-to-day life? The keyword seems to be ‘trigger’ when I’ve spoken to experts about its origins. “From my experience, trichotillomania can be triggered by a stressful or traumatic event – and hair pulling may be used as a coping mechanism, and as a way to initially alleviate feelings of anxiety,” says Anabel.

A genetic disposition has also been highlighted as a potential factor to increase a person’s susceptibility, as has levels of chemicals in the brain: “Studies using a technique called Positron Emission Tomography (PET) have shown that those affected by trichotillomania have raised levels of glucose metabolic activity,” says Nicky Lidbetter. “This supports an alternative theory that the disorder is the result of an imbalance of a brain chemical (called a neurotransmitter).”

Although stress is a particularly common trigger of TTM, its progression to the more habitual means that it can even occur at times of low stress. “Stressful circumstances frequently increase hair pulling behaviour but increased hair pulling can also occur in states of relaxation and distraction (for example, reading a book or watching television),” explains Nicky.

Interestingly also, some studies have suggested that hair pulling as a behaviour may already be present in our genetic make-up, indicating that a certain level may actually be perfectly healthy. Lucinda Ellery points out: “Professor Jon Grant from Chicago University, one of the top experts in ICD in the last 25 years, has highlighted a pre-disposition based on the fact that humanity shares 97% of the same DNA as our closest primates,” she says. “In the wild, pulling out hair is a social event. They pull hair and fur from each other and nibble their roots as it serves a social and loving function.” A fascinating factor to bear in mind when it comes to deciding your own personal indicators of what’s healthy and unhealthy.

How common is it?

Surprisingly more common than many think, with gender playing a pivotal role. “Trichotillomania is more common in women than in men and it is mainly seen in children, during puberty and also around menopause. However, it can occur at any age,” says Anabel.

This separation between the sexes is particularly interesting, with its reason remaining relatively unclear. “At present, researchers are unsure if this increased prevalence in women is a true reflection of the gender divide between those living with trichotillomania, or simply due to the fact that women are more likely to seek medical help for the problem than men,” says Nicky Lidbetter. “It could also be because it is more acceptable for men to have hair loss than women.”

As mentioned above, genetics, stress and anxiety can all play a part in the onset of trichotillomania. In her experience in the hair industry, Lucinda has also found certain traits noticeably more common in those affected too. “According to Professor Jon Grant, 100,000,000 people worldwide have experienced TTM. It’s also loud and clear from his findings that people who are susceptible to it are highly intelligent and deeply sensitive. We don’t know why this is though. In my own living experience, those affected hold powerful and successful positions. However, it’s a very private disorder as it touches on one of the most feminine parts of our being – our hair - and generally women don’t like talking about hair loss because it’s seen as a predominantly masculine trait. This is thankfully changing though.” So while women have been reported to be affected from the condition more than men, the numbers could actually be much higher due to the taboo that still surrounds the subject and women’s reluctance to open up about it.

For anyone affected by trichotillomania, I cannot stress enough that there is nothing to be ashamed of or embarrassed about

What are its symptoms?

“Those affected by trichotillomania will often have one or more thin or bald patches on their scalp - which can eventually cover quite a large area depending on the severity,” says Anabel Kingsley. “However, hairs are often pulled from areas that can be easily camouflaged and covered with the hair that is left – so it is not always immediately visible.”

There is often confusion though between hair loss caused by trichotillomania and hair loss caused by other conditions. “Trichotillomania is frequently misdiagnosed as alopecia areata – another type of hair loss that commonly occurs in patches,” explains Anabel. “Both conditions can look similar, and secondly, people are often ashamed and fearful to tell their doctor that they are intentionally pulling out their hair. However, there is a predominant diagnostic feature of trichotillomania: uneven hair breakage. When someone forcefully pulls their hair out, it cannot be pulled all at the same angle and so it snaps off, and at different lengths. Also, the pattern of hair loss from trichotillomania is usually worse on the right side of the scalp if someone is right-handed and vice versa.”

Prior tension and subsequent gratification when pulling out the hair have also been highlighted as common dimensions of TTM too.

Is it possible to overcome it?

Thankfully there’s now the support and resources needed to help change the habit. “For anyone affected by trichotillomania, I cannot stress enough that there is nothing to be ashamed of or embarrassed about,” says Anabel Kingsley. “At our clinics we have seen many individuals with this condition ranging from young children to highly successful women and men. The first and most important part of recovery is getting help either for yourself, a friend or family member.” She adds, “Just like recovery from any other condition, external support is essential.”

From a physical perspective

The best treatment and its efficacy is largely dependent on the severity of the hair loss caused. “All treatments for trichotillomania take time and patience, but the good news is that hair usually grows back as usual,” says Anabel. “However, if trichotillomania has been going on for an extended period of time, less hair may do so as hair follicles may become damaged, causing permanent loss of hair. Hair may also grow back a different texture in the areas affected. However, in most instances an improvement should be seen after the pulling is addressed and stopped.”

“Treatments for trichotillomania also include: wearing thick gloves or applying a slippery cream or conditioner, especially at night, when the temptation to pull hair out is at its greatest; cutting hair short so that it is difficult to grasp; and covering hair with a hat or scarf. Some people also find playing with worry beads is helpful as it provides a distraction. It is a matter of interrupting the habit. As shorter, broken hairs start to grow back, it can also be helpful to apply a pre-shampoo conditioning treatment to improve their strength and condition.”

Can supplements help? To a degree. “Supplements can be useful where hair is falling out in excess due to a nutritional deficiency or absorption problem,” explains Anabel. “If trichotillomania is accompanied by stress, this can be useful as stress can impede nutrient absorption. However, supplements will not help with the actual hair loss caused by hair pulling,” advises Anabel.

“If trichotillomania is being caused by or accompanied by depression or anxiety, certain prescription medications may be helpful – but it is essential that a doctor and psychologist are consulted for thorough advice,” she cautions.

Hair loss solutions

“There are ways to manage and avoid your TTM so you don’t have to face permanent hair loss as you get older,” says Lucinda Ellery. “The most important thing to bear in mind is to seek help and to not suffer in silence,” she emphasises. “There is plenty of help out there and the sooner you seek it, the less it will affect your everyday life. Our hair can have a huge impact on how we feel, so taking control of your hair loss and not allowing it to control you is key.” Here are her top tips:

Hair make up: “The reflection of light on the scalp really shows the gaps, but Fullmore scalp makeup is a brilliant cover up.”

Backbrushing: “Take the entire length of hair and, starting at the ends, not the root, sweep a bristle back to the scalp. Then style with your fingers.”

Clip-in hair pieces: “You need 6 – 8 inches of hair to use clip-in extensions, but they’re fantastic. They cost between £10 and £30, and don't have to be real hair.”

Medi connections: “With these ultra-fine hair extensions, you can cover a 10 inch patch for £250 - £350 and it’ll last for three months.”

Wigs: “These can feel hot, itchy and insecure, but they’re an excellent cover-up. Cut and style your wig and stitch it on the inside if it feels too loose. Try Trendco for great wigs costing between £50 and £100.”

Intralace: “Suitable for patches or the whole head, this is a mesh through which your own hair is lifted, strand-by-strand, and extensions added. It costs between £1,500 and £1,800, and lasts for two years, growing back with your real hair.”

Interlace is a service that Lucinda has found particularly effective with her clients. “It’s locked into the hair and surrounds the areas that are particularly vulnerable, so it makes it extremely hard to access them. This way, it gives those affected a chance to choose to do something different to break the habit,” she says. “You’re basically voluntarily denying yourself easy access.”

Eyebrow and eyelash loss solutions

With celebrities such as actress Olivia Munn sharing their stories of eyelash-centred TTM, this lesser known consequence of the condition is increasingly gaining greater awareness. “With TTM, eyebrows and eyelashes can often be the focus of the ‘nervous pulling’ and leave the puller with temporary, sometimes permanent sparseness or hair loss,” says makeup artist and brow expert Jenna Treat. If the condition has manifested itself in this way or similarly with your eyebrows, eyelash or eyebrow serums can prove particularly useful in helping stimulate regrowth of the hairs in question. “Growing serums such as those with leading medical ingredient lumigan or the protein hexatein have shown remarkable results in regrowth in a host of situations, including hair loss from TTM,” recommends Jenna. “RevitaBrow, £91, and RevitaLash, £39, are personal favourites, as is the long trusted drugstore brands RapidBrow, £37, and RapidLash, £41. Regrowth can take several weeks to appear, but this is one impactful way to get brows and lashes back to their original state, with minimal effort.”

“Cosmetically there are arsenals of products available to us now too,” advises Jenna. “Blink, the brow experts, has several magic tools to whip sparse brows into shape, such as its pencils or tinted brow gels, £17.”

When it comes to mascaras, which are the best ones for helping thicken thinning lashes? Colour selection proves key, says Jenna. “If extreme sparseness is an issue, perhaps a lighter shade than black is in order. Most mascaras come in a soft brown or soft black that can accentuate without eclipsing patchy areas,” she recommends. False eyelashes can also provide a useful go-to - Jenna’s top pick? “I have applied MAC 4 Lashes, £10.50, to a model with no lashes at all. Results were incredible and they looked like they were her own.”

Taking things one step further, in-salon services can help add volume and density when in the right hands. “Tinting lashes and brows is always a miracle working tip,” says Jenna. “This should be done by a professional who custom tints to accentuate without going overboard.”

Her advice does come with one caveat though: “Resist the urge to overdo enhancement with high definition products or treatments,” she warns. “This can backfire sometimes and call unwanted attention to uneven or patchy brows.”

Ultimately though, these are options that can assist if you’re feeling self-conscious and are by no means ‘rules’ for what you should do. “In the end, we must always remember that we are all individual,” says Jenna. “Some are more brow-endowed than others. Don't strive too hard for perfect brows or ultra lush lashes. Just try and make the best of what you have and own it.”

From a mental health perspective

As mentioned above, the reasons for a person’s TTM can vary widely and can be extremely complex. If the habit has become something that is affecting your day to day life and feels like it’s something out of your control, help is definitely at hand.

There is a range of services available that can assist in addressing stress and anxiety, to break old habits and build new ones going forward. Here are the treatments recommended by Anxiety UK.

1. Cognitive Behaviour Therapy (CBT)

A flexible therapy that can be tailored to fit your particular needs, cognitive behavioural therapy has been highlighted as an effective treatment by both experts and charities for its ability to address a wide range of mental health problems. “CBT currently has the largest amount of research carried out on its effectiveness in the treatment of anxiety and anxiety disorders,” says Nicky Lidbetter. “CBT focuses on what people think, how those thoughts affect them emotionally and how they ultimately behave.”

What can you expect from a session? “The therapist will help you examine your thought and behaviour patterns and help you to work on ways of changing these,” she explains. It differentiates itself from other types of therapy specifically because of its forward-looking approach. “This form of therapy focuses on the ‘here and now’ and is not overly concerned with finding the initial cause of anxiety,” explains Nicky.

For more information on where you can find a CBT therapist, click here. Anxiety UK also offers a CBT service to its members face-to-face, over the phone or via webcam too.

For a treatment that looks to examine the source of your anxiety as well as develop ways to cope with it moving forward, counselling looks to provide an alternative option. “Counselling is often used to explore issues in-depth and to allow for a focus on feelings associated with anxiety,” explains Nicky. “The most common form of counselling is known as Person Centred Counselling. This type of therapy seeks to explore the main issues from your unique perspective. Counselling is available through Anxiety UK face-to-face, via the telephone or via webcam.”

3. Clinical hypnotherapy

A type of therapy that has seen noticeable growth in the past few years is hypnotherapy, with Anxiety UK receiving consistently positive feedback from members who’ve done it. “It aims to provide people with results fairly quickly,” says Nicky. “Hypnotherapists will use a variety of techniques such as visualisation, which is aimed at producing quite deep levels of relaxation. Visualisation involves asking you to imagine a feared situation or object while you are in a deep state of relaxation. You are then asked to use positive visualisation to manage how you are feeling and to imagine the experience in a positive way.”

Anxiety UK offers clinical hypnotherapy to its members (call its helpline on 08444 775 774 to find out more) and you can also find clinical hypnotherapists in your area by visiting the Complementary and Natural Healthcare Council (CNHC) website at www.cnhc.org.uk.

Nicky highlights this as a valuable tool for those who suffer from panic attacks in particular. “These can be used as a way of enduring the thoughts for longer and longer periods and thus overcoming your anxiety by discovering that nothing bad happens even if you think about your anxiety or fear,” she explains. “Anxiety UK has a number of relaxation resources and products available at www.anxietyuk.org.uk. You can also find out more from your GP or a stress management class at your local Adult Education Centre,” she recommends. The charity also offers members access to the popular mindfulness app, Headspace, which is recommended in the treatment of stress and anxiety.

Medication isn’t for everyone, but it is an option for those who find their level of severity particularly hard to handle. “Anxiety medication may be prescribed if the fear is accompanied by frequent panic attacks, loss of sleep and also depression,” says Nicky. “It is important to note that medication will only help to alleviate symptoms and will not necessarily resolve any underlying issues,” she cautions though and recommends that other forms of treatments are taken alongside it.

The final word

Far more common than many think, if you are suffering from TTM, rest assured that you are not alone. “It’s about sharing and trying to stop people hiding in shame,” says Lucinda Ellery. What could you do if you think someone you care about has the condition? “I would ask sensitively if they have noticed the hair pulling and if you could do anything to help,” advises Professor David Veale, consultant psychiatrist at the Priory Hospital North London and The Maudsley Hospital. Hopefully the more people talk about it, the less people will feel that they have to suffer in silence.

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